Adult Health Final Exam.
When evaluating the patient's understanding about the care of the ileostomy, which statement by the patient indicates the patient needs more teaching? "I will be able to regulate when I have stools." "I will be able to wear the pouch until it leaks." "The drainage from my stoma can damage my skin." "Dried fruit and popcorn must be chewed very well."
"I will be able to regulate when I have stools." An ileostomy is in the ileum and drains liquid stool frequently, unlike a colostomy, which has more formed stool the farther distal the ostomy is in the colon. The ileostomy pouch is usually worn for 4 to 7 days or until it leaks. It must be changed immediately if it leaks because the drainage is very irritating to the skin. To avoid obstruction, popcorn, dried fruit, coconut, mushrooms, olives, stringy vegetables, food with skin, and meats with casings must be chewed extremely well before swallowing because of the narrow diameter of the ileostomy lumen.
The nurse is preparing to administer a dose of bisacodyl to a patient with constipation and the patient asks how it will work. What is the best response by the nurse? "It will increase bulk in the stool." "It will lubricate the intestinal tract to soften feces." "It will increase fluid retention in the intestinal tract." "It will increase peristalsis by stimulating nerves in the colon wall."
"It will increase peristalsis by stimulating nerves in the colon wall." Bisacodyl is a stimulant laxative that aids in producing a bowel movement by irritating the colon wall and stimulating enteric nerves. Fiber and bulk- forming drugs increase bulk in the stool. Water and stool softeners soften feces, and saline and osmotic solutions cause fluid retention in the intestinal tract.
The nurse is preparing to administer famotidine to a postoperative patient with a colostomy. The patient states they do not have heartburn. What response by the nurse would be the most appropriate? "It will reduce the amount of acid in the stomach." "It will prevent air from accumulating in the stomach, causing gas pains." "It will prevent the heartburn that occurs as a side effect of general anesthesia." "The stress of surgery is likely to cause stomach bleeding if you do not receive it."
"It will reduce the amount of acid in the stomach." Famotidine is an H2-receptor antagonist that inhibits gastric HCl secretion and thus minimizes damage to gastric mucosa while the patient is not eating a regular diet after surgery. Famotidine does not prevent air from accumulating in the stomach or stop the stomach from bleeding. Heartburn is not a side effect of general anesthesia.
The nurse is preparing to insert a nasogastric (NG) tube into a patient with a suspected small intestinal obstruction that is vomiting. The patient asks the nurse why this procedure is necessary. What response by the nurse is most appropriate? "The tube will help to drain the stomach contents and prevent further vomiting." "The tube will push past the area that is blocked and thus help to stop the vomiting." "The tube is just a standard procedure before many types of surgery to the abdomen." "The tube will let us measure your stomach contents so we can give you the right IV fluid replacement."
"The tube will help to drain the stomach contents and prevent further vomiting." The NG tube is used to decompress the stomach by draining stomach contents and thereby prevent further vomiting. The NG tube will not push past the blocked area. Potential surgery is not currently indicated. The location of the obstruction will determine the type of fluid to use, not measure the amount of stomach contents.
most common causes of large bowel blockage
#1 colorectal *CA* then *diverticular* disease and sigmoid *volvulus*
peritonitis s/s
*abd:* pain, tenderness (esp rebound) rigidity spasm distension bowel activity alteration stillness tachypneic, shallow breathing tachycardia fever N/V
IBD - cause, associated factors
*cause*: autoimmune genetic link + trigger *diet, air pollution, stress, smoking*: have effects on immune system and gut flora fats and meat: increased risk fruits, veg, and fiber: decreased risk OCPs and NSAIDs exacerbate Crohn's
purpose of surgery c peritonitis?
*explore* locate cause of inflammation *clean out* drain purulence *repair* damage e.g. perfs
UC: pattern of inflammation, location
*mucosal* layer affected *continuous* areas of inflammation *pseudopolyps* colitis = colon usually starts in rectum and progresses up colon
initial care for bowel obstruction
*rest* the bowel - NPO - NGT - TPN prn *replace* the F&E - IV fluid replacement (GI tract losses are isotonic) - potassium replacement PRN *pain* control - pain meds
Medications for IBD
*salicylates*: sulfasalazine, mesalamine *antimicrobials*: metronidazole, ciprofloxacin, clarithromycin *immunosuppressants*: methotrexate, cyclosporine, azathioprine *steroids*: prednisone, hydrocortisone *biologics*: mAB drugs - (the ones you see on afternoon TV ads) - Remicade, Humira, Cimzia, Tysabri
complication of surgery for Crohn's
*short bowel syndrome* from repeatedly resecting lengths of bowel can't maintain hydration/nutrition
management of IBD
- high cal, high protein, low residue diet - lactose free prn - TPN prn - medications - rest - counseling/therapy - surgery
hospital care of diverticulitis
- NPO - IV fluids, abx - keep an eye out for abscess, peritonitis, bleed - watch those WBCs - give pain meds - when getting better, start PO fluids then progress to semisolid food
surgical treatment of UC
- UC only affects colon, so total colectomy is curative - can do ileal pouch (eg Kock pouch): allows continence - if that doesn't/won't work: ileostomy When surgery is indicated: - more conservative Tx not working - complications like fistulas, obstructions, bleeds, perfs - suspected CA
goals of nutrition with IBD
- adequate nutrition - don't exacerbate s/s - maintain F&E - prevent wt loss no universal trigger foods - keep food diary
septicemia s/s
- fever - malaise - inc HR, RR - restless, disoriented - oliguria, dehydration - shock
large bowel obstruction s/s
- gradual onset *pain* - persistent pain *vomiting* - *none* until late *distention* - *present* *constipation* - *total,* no BM at all. bowel sounds present then become hypoactive.
UC: complications
- inc risk for and severity of C. diff - toxic megacolon - bowel perf r/t toxic megacolon - inc risk of colorectal CA
Nursing care for appendicitis: preop and postop
- maintain NPO - VS and assess for CIC - IV fluids, pain meds, antiemetics - NGT prn pre and postop postop care - usually lap so they go home within 24h - early amb within a few hours - advancing diet as tolerated - back to normal activity 2-3 weeks postop.
UC: characteristics
- onset young adult or older adult - constant abd pain - diarrhea - rectal bleeds - tenesmus (feeling like you need to poop even when you just did) - fever during exacerbations
Crohn's characteristics
- onset young adult or older adult - cramping abd pain - diarrhea - fever - weight loss - nutrition problems, malabsorption (fat and B12 absorbed in ileum only) - RLQ pain alleviated c BM
Crohn's: complications
- perianal abscesses and fistulas - strictures (scar tissue forms and is not stretchy, creates narrow areas in bowel) - inc risk for and severity of C. diff - bowel perf r/t full thickness inflammation - inc risk of small bowel CA (also of colorectal CA but not as much as with UC)
ostomy care: an appropriate pouching system is important to:
- protect the periostomy skin - dependable stool collection
small bowel obstruction s/s
- rapid onset *pain* - *colicky* pain *vomiting* - *present,* may be copious *distention* - may or may not be present *constipation* - *BMs gradually decreasing* to constipation boborygmi, visible peristaltic waves
surgical management of bowel obstruction
- resect affected segment - partial/total colectomy - colostomy or ileostomy - polyp rem, stricture dilation, tumor rem can often be done c colonoscopy
goals of surgery for colorectal CA
- resect tumor - exploratory - find mets - remove lymph nodes that drain area around CA - restore bowel continuity - prevent complications of surgery
A patient is scheduled to receive "Colace 100 mg PO." The patient asks to take the medication in liquid form, and the nurse obtains an order for the change. The available syrup contains 150 mg/15 mL. Calculate how many milliliters the nurse should administer. ___ mL
10
empty an ostomy bag when it is how full?
1/3
A patient is given a bisacodyl suppository and asks the nurse how long it will take to work. What is the best response by the nurse? 2 to 5 minutes 15 to 60 minutes 2 to 4 hours 6 to 8 hours
15 to 60 minutes Bisacodyl *suppositories* usually are effective within 15 to 60 minutes of administration, so the nurse should plan accordingly to assist the patient to use the bedpan or commode.
A patient with an intestinal obstruction has a nasogastric (NG) tube to suction but complains of nausea and abdominal distention. The nurse irrigates the tube as necessary as ordered, but the irrigating fluid does not return. What should be the priority action by the nurse? 1. Notify the physician. 2. Auscultate for bowel sounds. 3. Reposition the tube and check for placement. 4. Remove the tube and replace it with a new one.
3. Reposition the tube and check for placement. The tube may be resting against the stomach wall. The first action by the nurse is to reposition the tube and check it again for placement. The physician does not need to be notified unless the nurse cannot restore the tube function. The patient does not have bowel sounds, which is why the NG tube is in place. The NG tube would not be removed and replaced unless it was no longer in the stomach or the obstruction of the tube could not be relieved.
The nurse requests a patient scheduled for colectomy to sign the operative permit as directed in the physician's preoperative orders. The patient states that the physician has not really explained very well what is involved in the surgical procedure. What is the most appropriate action by the nurse? 1 Ask family members whether they have discussed the surgical procedure with the physician. 2 Have the patient sign the form and state the physician will visit to explain the procedure before surgery. 3 Explain the planned surgical procedure as well as possible and have the patient sign the consent form. 4 Delay the patient's signature on the consent and notify the physician about the conversation with the patient.
4 Delay the patient's signature on the consent and notify the physician about the conversation with the patient. The patient should not be asked to sign a consent form unless the procedure has been explained to the satisfaction of the patient. The nurse should notify the physician, who has the responsibility for obtaining consent.
The nurse is admitting a patient with severe dehydration and frequent watery diarrhea. A 10-day outpatient course of antibiotic therapy for bacterial pneumonia has just been completed. What is the most important for the nurse to take which action? 1 Wear a mask to prevent transmission of infection. 2 Wipe equipment with ammonia-based disinfectant. 3 Instruct visitors to use the alcohol-based hand sanitizer. 4 Don gloves and gown before entering the patient's room.
4 Don gloves and gown before entering the patient's room. Clostridium difficile is an antibiotic-associated diarrhea transmitted by contact, and the spores are extremely difficult to kill. Patients with suspected or confirmed infection with C. difficile should be placed in a private room, and gloves and gowns should be worn by visitors and health care providers. Alcohol-based hand cleaners and ammonia-based disinfectants are ineffective and do not kill all of the spores. Equipment cannot be shared with other patients, and a disposable stethoscope and individual patient thermometer are kept in the room. Objects should be disinfected with a 10% solution of household bleach.
A patient with suspected bowel obstruction had a nasogastric tube inserted at 4:00 AM. The nurse shares in the morning report that the day shift staff should check the tube for patency at what times? 7:00 AM, 10:00 AM, and 1:00 PM 8:00 AM, 12:00 PM, and 4:00 PM 9:00 AM and 3:00 PM 9:00 AM, 12:00 PM, and 3:00 PM
8:00 AM, 12:00 PM, and 4:00 PM A nasogastric tube should be checked for patency routinely at 4-hour intervals. Thus if the tube were inserted at 4:00 AM, it would be due to be checked at 8:00 AM, 12:00 PM, and 4:00 PM.
The nurse identifies that which patient is at highest risk for developing colon cancer? A 28-yr-old man who has a body mass index of 27 kg/m2 A 32-yr-old woman with a 12-year history of ulcerative colitis A 52-yr-old man who has followed a vegetarian diet for 24 years A 58-yr-old woman taking prescribed estrogen replacement therapy
A 32-yr-old woman with a 12-year history of ulcerative colitis Risk for colon cancer includes personal history of inflammatory bowel disease (especially ulcerative colitis for longer than 10 years); obesity (body mass index ?5= 30 kg/m2); family (first-degree relative) or personal history of colorectal cancer, adenomatous polyposis, or hereditary nonpolyposis colorectal cancer syndrome; eating red meat (?5=7 servings/week); cigarette use; and drinking alcohol (?5=4 drinks/week).
A patient is planned for discharge home today after ostomy surgery for colon cancer. The nurse should assign the patient to which staff member? A nursing assistant on the unit who also has hospice experience A licensed practical nurse that has worked on the unit for 10 years A registered nurse with 6 months of experience on the surgical unit A registered nurse who has floated to the surgical unit from pediatrics
A registered nurse with 6 months of experience on the surgical unit The patient needs ostomy care directions and reinforcement at discharge and should be assigned to a registered nurse with experience in providing discharge teaching for ostomy care. Teaching should not be delegated to a licensed practical/vocational nurse or unlicensed assistive personnel.
A colectomy is scheduled for a patient with ulcerative colitis. The nurse should plan to include which prescribed measure in the preoperative preparation of this patient? Instruction on irrigating a colostomy Administration of a cleansing enema A high-fiber diet the day before surgery Administration of IV antibiotics for bowel preparation
Administration of a cleansing enema Preoperative preparation for bowel surgery typically includes bowel cleansing with antibiotics, such as oral neomycin and cleansing enemas, including Fleet enemas. Instructions to irrigate the colostomy will be done postoperatively. Oral antibiotics are given preoperatively and an IV antibiotic may be used in the operating room. A clear liquid diet will be used the day before surgery with the bowel cleansing.
Which clinical manifestations of inflammatory bowel disease does the nurse determine are common to both patients with ulcerative colitis (UC) and Crohn's disease (select all that apply.)? Restricted to rectum Strictures are common Bloody, diarrhea stools Cramping abdominal pain Lesions penetrate intestine
Bloody, diarrhea stools Cramping abdominal pain Clinical manifestations of UC and Crohn's disease include bloody diarrhea, cramping abdominal pain, and nutritional disorders. Intestinal lesions associated with UC are usually restricted to the rectum before moving into the colon. Lesions that penetrate the intestine or cause strictures are characteristic of Crohn's disease.
The nurse is preparing to administer a scheduled dose of docusate sodium when the patient reports an episode of loose stool and does not want to take the medication. What is the appropriate action by the nurse? Write an incident report about this untoward event. Attempt to have the family convince the patient to take the ordered dose. Withhold the medication at this time and try to administer it later in the day. Chart the dose as not given on the medical record and explain in the nursing progress notes.
Chart the dose as not given on the medical record and explain in the nursing progress notes. Whenever a patient refuses medication, the dose should be charted as not given with an explanation of the reason documented in the nursing progress notes. In this instance, the refusal indicates good judgment by the patient, and the patient should not be encouraged to take it today.
When teaching the patient about the diet for diverticular disease, which foods should the nurse recommend? White bread, cheese, and green beans Fresh tomatoes, pears, and corn flakes Oranges, baked potatoes, and raw carrots Dried beans, All Bran (100%) cereal, and raspberries
Dried beans, All Bran (100%) cereal, and raspberries A *high-fiber diet is recommended for diverticular disease*. Dried beans, All Bran (100%) cereal, and raspberries all have higher amounts of fiber than white bread, cheese, green beans, fresh tomatoes, pears, corn flakes, oranges, baked potatoes, and raw carrots.
After an exploratory laparotomy, a patient on a clear liquid diet reports severe gas pains and abdominal distention. Which action by the nurse is most appropriate? Return the patient to NPO status. Place cool compresses on the abdomen. Encourage the patient to ambulate as ordered. Administer an as-needed dose of IV morphine sulfate
Encourage the patient to ambulate as ordered. Swallowed air and reduced peristalsis after surgery can result in abdominal distention and gas pains. Early ambulation helps restore peristalsis and eliminate flatus and gas pain. Medications used to reduce gas pain include metoclopramide, which stimulates peristalsis. A heating pad can help to alleviate some of the pain and help make the patient more comfortable. There is no need for the patient to return to NPO status. Drinking ginger ale may be helpful.
A patient after a stroke who primarily uses a wheelchair for mobility has developed diarrhea with fecal incontinence. What is a priority assessment by the nurse? Fecal impaction Perineal hygiene Dietary fiber intake Antidiarrheal agent use
Fecal impaction Patients with limited mobility are at risk for fecal impactions caused by constipation that may lead to liquid stool leaking around the hardened impacted feces, so assessing for fecal impaction is the priority. Perineal hygiene can be assessed at the same time. Assessing the dietary fiber and fluid intake and antidiarrheal agent use will be assessed and considered next.
A patient is admitted to the emergency department after a motor vehicle crash with suspected abdominal trauma. What assessment finding by the nurse is of highest priority? Nausea and vomiting Hyperactive bowel sounds Firmly distended abdomen Abrasions on all extremities
Firmly distended abdomen Clinical manifestations of abdominal trauma are guarding and splinting of the abdominal wall; a hard, distended abdomen (indicating possible intraabdominal bleeding); decreased or absent bowel sounds; contusions, abrasions, or bruising over the abdomen; abdominal pain; pain over the scapula; hematemesis or hematuria; and signs of hypovolemic shock (tachycardia and decreased blood pressure).
diagnosing bowel obstruction
H&P imaging sigmoidoscopy or colonoscopy CBC (watch for bleeds, infection) metabolic panel (watch for alkalosis)
how is appendicitis Dx'ed?
H&P physical exam CBC c WBC differential UA to r/o a UTI or whatever that could mimic s/s imaging: *CT (preferred),* ultrasound, MRI
The nurse is caring for a patient admitted with a suspected bowel obstruction. The nurse auscultating the abdomen listens for which type of bowel sounds that are consistent with the patient's clinical picture? Low-pitched and rumbling above the area of obstruction High-pitched and hypoactive below the area of obstruction Low-pitched and hyperactive below the area of obstruction High-pitched and hyperactive above the area of obstruction
High-pitched and hyperactive above the area of obstruction Early in intestinal obstruction, the patient's bowel sounds are hyperactive and high pitched, sometimes referred to as "tinkling," above the level of the obstruction. This occurs because peristaltic action increases to "push past" the area of obstruction. As the obstruction becomes complete, bowel sounds decrease and finally become absent.
The nurse is developing a plan of care for a patient with an abdominal mass and suspected bowel obstruction. Which factor in the patient's history does the nurse recognize as increasing the patient's risk for colorectal cancer? Osteoarthritis History of colorectal polyps History of lactose intolerance Use of herbs as dietary supplements
History of colorectal polyps A history of colorectal polyps places this patient at risk for colorectal cancer. This tissue can degenerate over time and become malignant. Osteoarthritis, lactose intolerance, and the use of herbs do not pose additional risk to the patient.
What information would have the highest priority for the nurse to include in preoperative teaching for a patient scheduled for a colectomy? How to care for the wound How to deep breathe and cough The location and care of drains after surgery Which medications will be used during surgery
How to deep breathe and cough Because anesthesia, an abdominal incision, and pain can impair the patient's respiratory status in the postoperative period, it is of high priority to teach the patient to cough and deep breathe. Otherwise, the patient could develop atelectasis and pneumonia, which would delay early recovery from surgery and hospital discharge. Care for the wound and location and care of the drains will be briefly discussed preoperatively but will be done again with higher priority after surgery. Knowing which drugs will be used during surgery may not be meaningful to the patient and should be reviewed with the patient by the anesthesiologist.
Two days after a colectomy for an abdominal mass, a patient reports gas pains and abdominal distention. The nurse plans care for the patient based on the knowledge that the symptoms are occurring as a result what event? Impaired peristalsis Irritation of the bowel Nasogastric suctioning Inflammation of the incision site
Impaired peristalsis Until peristalsis returns to normal after anesthesia, the patient may experience slowed gastrointestinal motility, leading to gas pains and abdominal distention. Irritation of the bowel, nasogastric suctioning, and inflammation of the surgical site do not cause gas pains or abdominal distention.
s/s diverticulitis
LLQ *pain* palpable abd *mass* *N/V* *fever* (maybe no fever in old people)
A hospitalized patient has just been diagnosed with diarrhea due to Clostridium difficile. Which nursing interventions should be included in the patient's plan of care (select all that apply.)? Select all that apply. Initiate contact isolation precautions. Place the patient on a clear liquid diet. Disinfect the room with 10% bleach solution. Teach any visitors to wear gloves and gowns. Use hand sanitizer before and after patient or bodily fluid contact.
Initiate contact isolation precautions. Disinfect the room with 10% bleach solution. Teach any visitors to wear gloves and gowns. Initiation of contact isolation precautions must be done immediately with a patient with C. difficile, which includes washing hands with soap and water before and after patient or bodily fluid contact. Alcohol-based sanitizers are ineffective. Visitors need to be taught to wear gloves and gowns and wash hands. A clear liquid diet is not necessary. The room will be disinfected with 10% bleach solution when the patient is dismissed and may be done periodically during the patient's stay, depending on the agency policy.
The nurse is administering a cathartic agent to a patient with renal insufficiency. Which order will the nurse question? Bisacodyl Lubiprostone Cascara sagrada Magnesium hydroxide
Magnesium hydroxide Milk of Magnesia may cause hypermagnesemia in patients with renal insufficiency. The nurse should question this order with the health care provider. Bisacodyl, lubiprostone, and cascara sagrada are safe to use in patients with renal insufficiency as long as the patient is not currently dehydrated.
The nurse is conducting discharge teaching for a patient with metastatic lung cancer who was admitted with a bowel impaction. Which instructions would be most helpful to prevent further episodes of constipation? Maintain a high intake of fluid and fiber in the diet. Discontinue intake of medications causing constipation. Eat several small meals per day to maintain bowel motility. Sit upright during meals to increase bowel motility by gravity.
Maintain a high intake of fluid and fiber in the diet. Increased fluid intake and a high-fiber diet reduce the incidence of constipation caused by immobility, medications, and other factors. Fluid and fiber provide bulk that in turn increases peristalsis and bowel motility. Analgesics taken for lung cancer probably cannot be discontinued. Eating several small meals per day and position do not facilitate bowel motility.
The nurse should administer an as-needed dose of magnesium hydroxide after noting what information when reviewing a patient's medical record? Abdominal pain and bloating No bowel movement for 3 days A decrease in appetite by 50% over 24 hours Muscle tremors and other signs of hypomagnesemia
No bowel movement for 3 days Magnesium hydroxide is an osmotic laxative that produces a soft, semisolid stool usually within 15 minutes to 3 hours. This medication would benefit the patient who has not had a bowel movement for 3 days. It would not be given for abdominal pain and bloating, decreased appetite, or signs of hypomagnesemia.
Low-residue diet is characterized by?
No high-fiber foods Residue = stuff that doesn't get digested
cause of colorectal CA?
No single causative factor. High risk: FHx of CRC and IBD. Hx polyps, IBD. Other risk factors: red meat, obesity, smoking, inactivity, ETOH, DM2, being AA.
s/s of colorectal CA
Nonspecific s/s - fatigue, wt loss. Fe-def anemia, rectal bleed, bowel pattern change, bowel obstruction/perforation. Late s/s include abd pain, palpable abd mass, ascites, hepatomegaly (liver = common site for mets)
The nurse is preparing to administer a daily dose of docusate sodium to a patient that will continue taking it after discharge. What information should the nurse provide to the patient to optimize the outcome of the medication? Take a dose of mineral oil at the same time. Add extra salt to food on at least one meal tray. Ensure a dietary intake of 10 g of fiber each day. Take each dose with a full glass of water or other liquid.
Take each dose with a full glass of water or other liquid. Docusate lowers the surface tension of stool, permitting water and fats to penetrate and soften the stool for easier passage. The patient should take the dose with a full glass of water and should increase overall fluid intake, if able, to enhance effectiveness of the medication. Dietary fiber intake should be a minimum of 20 g daily to prevent constipation. Mineral oil and extra salt are not recommended.
The wound, ostomy, and continence nurse (WOCN) selects the site where the ostomy will be placed. What should be included in site consideration? The patient must be able to see the site. The site should be outside the rectus muscle area. It is easier to seal the drainage bag to a protruding area. A waistline site will allow using a belt to hold the appliance in place.
The patient must be able to see the site. In selection of the ostomy site, the WOC nurse will want a site visible to the patient so the patient can take care of it, within the rectus muscle to avoid hernias, and on a flat surface to more easily create a good seal with the drainage bag. Care should be taken to avoid skin creases, scars, and belt lines, which can interfere with the adherence of the appliance.
where are mechanical bowel obstructions usually found
small bowel
what is an intestinal infarct
aka intestinal strangulation severe bowel ischemia leads to edema, cyanosis, gangrene, possible perf of a segment
what is the Tx for appendicitis
appendectomy, preferably before it ruptures, and abx (usually start IV abx before sx)
causes of peritonitis - primary:
blood-borne MOs genital tract MOs cirrhosis c ascites
what is a volvulus
bowel twists like it's trying to be a balloon animal
two common types of ostomies are
colostomy ileostomy
pt teaching to prevent diverticular disease
eat vegetables and fruits not too much red meat or fat lots of water lose weight probably exercise wouldn't hurt avoid increasing intraabd pressure (N/V, constipation, bending, lifting, tight clothing) they used to teach that you should avoid nuts and seeds bc they can get stuck in the diverticula but apparently not anymore. so eat that granola. but it'll probably still say on test questions to avoid it.
lots of things can cause abd pain. what is found in each area?
epigastric pain can be r/t: PUD, MI, chole, pancreatitis *RLQ*: appendix, bowel, ureter, bladder, genital *RUQ*: liver, gallbladder, kidney, ureter *LUQ*: stomach, kidney, ureter *LLQ*: bowel, ureter, bladder, genital periumbilical pain can be r/t: small/large bowel obstruction, early appendicitis, AAA
complications of diverticulitis
erosion of bowel wall -> perf if body able to wall off perf -> abscess if not -> peritonitis
Crohn's: pattern of inflammation, location
full thickness of bowel affected skip lesions cobblestoning occur anywhere in GI tract (from mouth to anus) most common site is distal ileum and proximal colon
tx for bowel obstruction
gastric decompression but may need surgery
Diagnosing IBD
goal: R/O other diseases, then differentiate between UC and Crohn's *labs* CBC: anemia? WBC: infection? lytes: vomiting or diarrhea? albumin: nutrition? ESR, CRP: inflammation? *imaging* contrast barium enema U/S, CT, MRI colonoscopy to visualize tissue, ulcerations, pseudopolyps, strictures, obtain Bx
s/s appendix has perfed
inc pain high fever (remember old ppl may not have fever)
where are diverticula most common
left (descending, sigmoid) colon
goal of care for acute diverticulitis?
let the colon *rest* let *inflammation subside* maybe can do @ home c PO abx and clear liquids maybe going to have to go to the hospital if it's bad.
the extent of F&E problems in a bowel obstruction depends on
location: duodenum - metabolic alkalosis possible from N/V or NGT suction small bowel - rapid dehydration large bowel - F&E imbalances don't occur until late
tx for stage 2 CRC
lower-risk: wide resection & anastomosis higher-risk: wide resection & anastomosis plus chemo
tx for stage 3 CRC
maybe: XRT/chemo a surgery surgery chemo
the more distal the ostomy, the bowel movements will appear
more distal = more normal BM most water resorbed in colon, so ileostomies tend to have *watery* loose effluent
diagnosing diverticulitis
obtain H&P CT c contrast abd/CXR to r/o other causes
what happens in mechanical bowel obstruction
physical blockage in the lumen
appendicitis diagnostic signs
rebound pain @ McBurney's point Psoas sign: hyperextension of leg Rovsing's sign: palpation of LLQ increases pain in RLQ
what is a nonmechanical bowel obstruction
reduced or absent peristalsis can be neuromuscular or vascular most common type is *paralytic ileus*
tx for stage 1 CRC
remove tumor and >=5cm of bowel on either side remove nearby lymph nodes
Grains that are OK on low-residue?
rice cream of wheat or grits rice krispies or corn flakes white bread, saltines
a happy stoma looks?
rose to brick red
postop CRC drainage is usually
serosanguineous
nursing care of peritonitis
similar to appy management - NPO, pain, N/V, fluids; WBC; imaging May not have sx if mild case or poor sx candidate - just get abx, NGT, pain meds, IV fluids.
3 types of appendicitis
simple gangrenous perfed
causes of nonmechanical bowel obstruction
some degree of paralytic ileus happens p any *abd sx. * other causes: - *peritonitis* - acute *inflammation* (eg pancreatitis, appendicitis) - hypokalemia or other lytes off - T- or L-*spine fracture*
common causes of small bowel obstruction
surgical *adhesions* also *hernia, strictures, intussusception*
what if pt gets diverticulitis a lot, or gets complications?
that sucks :( they probably need a colon resection maybe a temporary colostomy while stuff heals
treatment of bowel obstruction depends on...
the cause - find and alleviate
2 types of inflammatory bowel disease
ulcerative colitis Crohn's
surgical Tx of Crohn's
usually done to address complications: - strictures - obstructions - bleeds - fistulas remove segment and anastomose ends of remaining bowel. (problem: recurrence often occurs at anastomosis)
diagnosing diverticulosis
usually found during routine sigmoid/colonoscopy
tx for stage 4 CRC
usually palliative - chemo, XRT to control spread and alleviate pain. some stage IV c limited lung/liver mets may be able to be cured
perioperative CRC care
varies! - some may bowel prep, some may not - may be able to maintain bowel function - or may have an ostomy - may have drains - may have open, packed wounds
what are diverticula? diverticulosis? diverticulitis?
*diverticula*: saccular dilations/outpouchings of the colon mucosa *diverticulosis*: having diverticula they're common, esp in older adults, but most people don't get *diverticulitis*, wherein they become inflamed/bleed
IBD postop care
- usual postop concerns - monitor stoma - initial high ileostomy output - 1.5-1.8L in 1st 24h - monitor F&E - monitor for return of bowel - high *risk of obstruction* in first month